Mount Carmel Bluffs

In the surveyor’s words

From the most serious findings on record at Mount Carmel Bluffs, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Jul 9, 2025

  Based on observation, clinical record review, staff interview and facility policy review, the facility failed to assure all residents remained in a safe and secure environment with all hazardous items locked and/or contained in a safe area not accessible to residents (Residents #7, #8 and #9). The facility identified a census of 56 residents. Findings include: On 6/25/25 at 2:24 PM observed an unattended 4 wheeled utility cart that had 2 open shelves positioned outside of occupied room [ROOM NUMBER]. The cart contained deodorant spray and disinfectant wipes. Both bottles directed to keep out of reach of children. In addition, noted 3 pairs of pointed edged scissors accessible on the cart. […]

• No harm, potential for more than minimal, patternF812Apr 4, 2024

  Based on observation, policy review, and staff interview the facility failed to use gloves appropriately for assembling and serving meals, keep hands off the eating surfaces of dishes, wear hair nets appropriately, keep the ice machines clean, and date opened foods in order to serve meals under sanitary conditions. The facility reported a census of 46 residents. Findings include: Observation of the first floor kitchenette on 4/01/23 at 9:40 AM revealed the following: a. One small, round, white, four inch cardboard container, with an unknown food substance, undated in the refrigerator. b. One six inch plastic container with one piece of Lasagna Classico, labeled with a resident's name, undated. c. […]

• No harm, potential for more than minimal, isolatedF725Feb 26, 2026

  Based on clinical record review, observation, resident and staff interviews, call light logs, and policy review the facility failed to respond to resident needs in a timely manner for 1 of 2 residents reviewed (Resident #7). Residents waited more than 15 minutes for call lights to be answered and Resident #7 stated she was not able to hold her urine while waiting. The facility reported a census of 55 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. […]

• No harm, potential for more than minimal, isolatedF550Jul 9, 2025

  Based on observation, clinical record review, resident interview, staff interview and review of the facilities Resident's Rights form revealed the staff failed to treat 2 out of 3 residents with dignity and respect during care as a means to maintain their individual resident rights. (Residents #4 and #5)Findings include:1. Resident #4's Minimum Data Set (MDS) assessment form dated 4.8.25 identified a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS listed Resident #4 as non-ambulatory, required substantial to maximum assistance with toileting hygiene, and partial to moderate assistance with toilet transfers. The MDS included diagnoses of renal insufficiency (impaired kidney function), diabetes mellitus (DM) and chronic respiratory failure. […]

• No harm, potential for more than minimal, isolatedF684Jul 9, 2025

  Based on observations, clinical record review, staff interview and facility policy review, the facility failed to complete an adequate assessment and intervention for 3 of 3 residents following a change in condition (Residents #3, #6 and #7). The facility identified a census of 56 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #3 depended on the staff to rolling left and right in bed, she didn't attempt to walk due to safety concerns or medical conditions and didn't use a wheelchair.An observation on 6/25/25 at approximately 3:05 PM revealed Resident #3 had a bandage on her left lower forearm. […]